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Drowning Update
Daniel Brody MD, FRCPC, FAAPPediatric Emergency Medicine
Trauma RoundsApril 29, 2013
Disclosure statement
I have no known financial or commercial interest connected with this presentation
Objectives
• Overall burden of drowning• Epidemiology
• Quebec drowning “epidemic”
• Outcome in survivors
• Prevention
Injury mortality‐North America: 0‐18y
www.cdc.gov/injury/2010
Morbidity of injury
WHO childhood injury report. 2004, 2008
Injury mortality worldwide
WHO childhood injury report. 2008
Drowning definition •33 definitions of drowning
– Near drowning– Dry vs. wet drowning– Active vs. passive– Secondary
a process resulting in primary respiratory impairment from submersion in a liquid
medium
Papa et al., Resuscitation. 2005World congress on drowning. Amsterdam, 2002
Drowning definition
World congress on drowning. Amsterdam 2002
Epidemiology: worldwide
WHO injury report. 2008
Epidemiology: southeast Asia
•Drowning > pertussis + diphteria
+measles +
cholera + dengue + typhoid
WHO. Childhood injury report. 2008
Epidemiology: USA
cdc.gov/injury/drowning
Epidemiology: Canada
Canadian drowning report. lifesaving society 2012
Epidemiology: Canada (incidence)
Secretériat au loisir et au sport. Rapport. 2009
Epidemiology: Québec
Secretériat au loisir et au sport. Rapport. 2009
Drowning: age + body of water
Canadian Red Cross. 2003-2008 drowning report
Epidemiology: death rates
CHIRPP database.PHAC. 2008
Body of water: Canada
Secretériat au loisir et au sport. Rapport. 2009CHIRPP database.PHAC. 2008
7%
17-19%
Residential pool drownings
Canadian Red Cross. 2003-2008 drowning report
Summer 2012
“Drowning Epidemic”
1 toddler drowning every 2.1 days
July 9:St.EphremDeBeauce–18mo
June 26: lacdes lièvres – 4y
Drowning deaths in Quebec
2012~72-74
Toddler drownings
Residential pool drownings
Secretériat au loisir et au sport. Rapport. 2009
Google images – summertime in Montreal
People per pool
1) Florida 19
2) Quebec 26
3) California 31
cdc.gov/homeandrecreationalsafety/waterinjuries
> 300,000 pools in Quebec
Residential pool drownings
Ran outside, unfenced pool
Broken patio lock, unfenced
Walking along pool, adults talking
Parent went in to answer phone
Fell into pool approx 12 secs
Ran outside, died in ICU 2 days later
Residential pool drownings
Canadian Red Cross. 2003-2008 drowning report
Pool supervision
Safe Kids Campaign: National study of childhood drowning. Washington DC. 2004
Pool supervision
Safe Kids Campaign: National study of childhood drowning. Washington DC. 2004
Pathophysiology
SUBMERSION
“Hypoxemic” HYPOXIA
MULTI‐ORGAN DYSFUNCTION
Drowning Process
Szpilman et al., NEJM. 2012
(100%)
Management
• ATLS/PALS
• C‐spine• Hypothermia• Salt vs
freshwater
• Antibiotics• Steroids• ICU care
Outcome•Severity of initial ischemic brain insult
•Effectiveness of “on‐scene”
resuscitation
•Transfer to ED + ED care•Post‐resuscitation management1:4
1:4
3:1
Suominen. JTREM. 20123 : 1
Prognosis
• Determinants– Duration of submersion
• > 5 minutes
– Need for CPR– Duration of CPR– Spont. breathing + circulation restored in the ED– Time to regain consciousness
• Assessment– Serial PICU neuro evaluation– MRI Zuckerman et al. ArchPedAdol. 1998
Quan et al. Pediatrics. 1990
Long‐term outcome
•Large methodological heterogeneity•No studies > 5 year follow-up •No two studies use same neuropsychologic tools•Neuro exam at discharge not predictive of long- term outcome
– May not manifest until school age– Similar pattern seen in studies of other hypoxic
events in young children
Suominen et al., JTREM. 2012
QOL post drowning
Suominen et al., Resuscitation. 2011
Prevention
• Swimming lessons *
• Fencing *• More specific
– Supervision * – Alcohol– Boating safety– Ice safety– Epilepsy
“The spike in drownings
prompted Jean Charest's government to announce it would
implement a "swim to survive" program piloted in several schools two years ago.
The program would target children in Grade 3 and promote basic swimming skills to survive a fall in deep water. “
www.coroner.gouv.qc.ca
Swimming lessons
• > 5y.o. – can prevent drowning– float on back > 30 seconds– Stand in 2 ft
of water
• < 5y.o –
controversial !
• AAP: Swimming for toddlers recommended but not as a drowning prevention strategy
Weiss et al; Pediatrics. 2010Canadian red cross. 2010AAP:Policy statement-drowning.2010
Supervision
• Minimum swimming level
• Lifeguards• Chaperones (1 for every 4‐5 kids)• Buddy system
Pelletier et al., InjPrev. 2011
Fencing• Australia: mandatory fencing 1994
• Retrospective review: 2000– 32 toddler drownings– 28/32: one or both parents home
– 6/32: considered “good swimmers”
– Fencing• 3 complete fences
• 18 incomplete fences
• 11 no fence
Blum et al., Resuscitation. 2000
Fencing
• Do pool fences prevent death from drowning?
Thompson et al., Cochrane review. 2010
Fencing
• 4 sided fence• All pools• High enough/not climbable• Locked gate• Enforced legislation
– Fines– Regular inspections
• Media campaigns
Thompson et al., Cochrane review. 2010
Fencing: Quebec law
• In‐ground, above ground + inflatable pools >.6m deep
• 4 sided fence• Minimum ht = 1.22m• “style”
that inhibits climbing
• Self closing/latching gate• Penalty: $500‐700 (repeat offences: $700‐1000)
• Municipal enforcement• Municipal permits• Applicable to pools installed
after Oct 31, 2010
Residential swimming pool safety act. chapter S-3.1.02, r. 1cx
Prevention: coroner.gouv.qc.ca
• 2008: diving board report• 2011: St‐Sauveur water park report• 2012: swim to survive program
Resources• Review articles
– Szpilman
et al., Drowning. NEJM. 2012. 366;22
– mels.gouv.qc.ca/loisirsport/pdf/FaitsSaillantsNoyadeAnglais.pdf
– Lifesaving.ca/contect/english/pdf/CLS%20Drowning%202012E_WEB.p
df
– cdc.gov
(injury–
water safety)
• Long‐term outcome– Suominen
et al., JTREM. 2012. 20;55
• Prevention– Weiss et al., Pediatrics. 2010. 126;e253
– Mapiscinesécuritaire.com
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